Healthcare Provider Details

I. General information

NPI: 1417963836
Provider Name (Legal Business Name): LAUREEN MARY TAVOLARO-RYLEY RN, MSN, CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 S BROAD ST
PHILADELPHIA PA
19147-4919
US

IV. Provider business mailing address

1427 S BROAD ST
PHILADELPHIA PA
19147-4919
US

V. Phone/Fax

Practice location:
  • Phone: 215-300-0275
  • Fax: 215-336-6415
Mailing address:
  • Phone: 215-300-0275
  • Fax: 215-336-6415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN269156L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: